TL;DR

Exactly one year after receiving our seed funding upon completion of the Charity Entrepreneurship program, we (Miri and Evan) look back on our first year of operations, discuss our plans for the future, and launch our fundraising for our Year 2 budget.

Family Planning could be one of the most cost-effective public health interventions available. Reducing unintended pregnancies lowers maternal mortality, decreases rates of unsafe abortions, and reduces maternal morbidity. Increasing the interval between births lowers under-five mortality. Allowing women to control their reproductive health leads to improved education and a significant increase in their income. Many excellent organisations have laid out the case for Family Planning, most recently GiveWell.^[1]

In many low and middle income countries, many women who want to delay or prevent their next pregnancy can not access contraceptives due to poor supply chains and high costs. Access to Medicines Initiative (AMI) was incubated by Ambitious Impact’s Charity Entrepreneurship Incubation Program in 2024 with the goal of increasing the availability of contraceptives and other essential medicines.^[2]

The Problem

Maternal mortality is a serious problem in Nigeria. Globally, almost 28.5% of all maternal deaths occur in Nigeria. This is driven by Nigeria’s staggeringly high maternal mortality rate of 1,047 deaths per 100,000 live births, the third highest in the world. To illustrate the magnitude, for the U.K., this number is 8 deaths per 100,000 live births.  

While there are many contributing factors, 29% of pregnancies in Nigeria are unintended. 6 out of 10 women of reproductive age in Nigeria have an unmet need for contraception, and fulfilling these needs would likely prevent almost 11,000 maternal deaths per year.

Additionally, the Guttmacher Institute estimates that every dollar spent on contraceptive services beyond the current level would reduce the cost of pregnancy-related and newborn care by three dollars. The Copenhagen Consensus also found that every dollar spent on access to modern contraception leads to 120 dollars of social, economic, and environmental benefits.

Many fantastic organisations work to increase demand for contraceptives, especially by educating women and families (such as Family Empowerment Media). Unfortunately, many women living in low and middle income countries are unable to reap the benefits of contraceptives due to a lack of access. On average, Nigerian public health facilities are stocked out of at least one form of contraceptive 78% of the time, though this figure is even worse in the aftermath of the USAID withdrawal. Contraceptive stockouts are a well documented issue. In the areas where we work, 56% to 88% of the population lives below the poverty line, and most families who want to access contraception are unable to afford the private market. We aim to empower these families to access the contraceptive method of their choice by improving access to free, safe contraceptives in the Nigerian public health system.

Year 1 Retrospective

Pilot

Over the past seven months, we’ve run a pilot across 137 primary and secondary health facilities in Katsina and Sokoto states in Northern Nigeria.

This pilot had three goals:

1. Diagnose the specific problems in Nigeria’s public contraceptive supply chain and understand which ones matter most.
2. Measure how much contraceptive uptake increases with improved availability.
3. Refine promising cost-effective solutions to improve the supply chain.

We selected six Local Government Areas (LGAs) in Katsina and three in Sokoto, enrolling all health facilities providing family planning services within them — a total of 137 facilities (74 in Katsina, 63 in Sokoto). These pilot LGAs account for roughly 10–20% of the total population in each state.

To inform our work and test different approaches to improving data visibility, we designed three distinct versions of a mobile-based data collection system. Each facility was randomly assigned and trained to use only one version, allowing us to A/B test which approach was most effective in supporting accurate and timely reporting. We provided small monthly data stipends to encourage consistent data entry. To verify consumption data and track inventory, we hired Monitoring & Evaluation (M&E) officers in each LGA. They visited every facility regularly to collect data from all patient registers, collect data from stock registers, as well as conduct physical stock counts.

We designed a register where health workers could keep track of the number of patients coming in for a Family Planning consultation but leaving without contraceptives, as well as their reasons for doing so. The main reasons include stockouts of their desired method, fear of side effects of other methods, needing to obtain their husbands approval, and being unable to afford the mandatory pregnancy test. Each participating facility filled this register over the duration of the pilot. Previously, this data was not captured in facilities.

We also collected distribution data from LGA and state-level officials, which we cross-referenced with facility-level reports to understand how commodities move through the public system.

By digitising and triangulating all these data sources - from state warehouses down to patient-level use - we built a comprehensive picture of how contraceptives are allocated, delivered, and consumed across these two states.

As part of the pilot, we ran a pre-post study to assess the impact of improved supply on contraceptive use. Facilities in 2 LGAs in Katsina and 1 LGA in Sokoto received deliveries of contraceptives we procured in addition to their regular supply, while the remaining facilities served as controls. Each delivery was aimed to provide 2 months of supply, matching the typical delivery interval, and was based on historical consumption data.

3 deliveries were made in total, with the selected procurement LGAs in Katsina receiving 2 deliveries of commodities, and the selected facilities in Sokoto receiving 1 delivery.

By measuring changes in consumption before and after these deliveries, we wanted to quantify the impact of supply alone, isolating how much unmet demand can be unlocked simply by ensuring commodities are available in public health facilities.

We included a broad range of contraceptive methods in these deliveries to get a comprehensive picture of the demand for all modern contraceptives. Due to differing side effects and life circumstances, the ability to choose a preferred method can make the difference between accessing contraception or leaving a facility empty-handed.

Preliminary Pilot Results^[3]

Increasing the Total Amount of Contraceptives

A key result of our pilot is an increase in consumption in response to our deliveries.

Our first delivery to Katsina State supplied contraceptives to 23 participating health facilities. After comparing consumption data before and after the delivery, while consumption remained roughly unchanged in our control regions, in LGAs that received additional contraceptives:

• Pill consumption increased 50%,
• Injectable consumption increased 40%,
• Condom consumption increased 240%, and
• Implant consumption increased 20%.

From this delivery alone, we estimate that we generated around 224 additional Couple Years of Protection (CYP) - equivalent to protecting 224 women for one year each. This averted approximately 110 unintended pregnancies.

Based on our current model, we believe our delivery saved around 50 DALYs and saved 1–2 lives.

The procurement cost for this delivery was about $3,100, with an additional $200 for transportation and handling.

Notably, we sought to provide more contraceptives than our data indicated would be necessary over the typical 2-month resupply period. However, many facilities showed a much higher demand than anticipated, with some running out of stock within just a few weeks. In response, we increased the quantities for our second delivery to Katsina, and we predict the impact could be even greater. We expect to have the full analysis of this delivery in May.

We are currently digitising and analysing data from our delivery to 20 health facilities in Sokoto. Given that baseline stockout levels in Sokoto were significantly higher than in Katsina, we expect the impact of our intervention to be even greater.

Alongside contraceptive commodities, we also supplied essential auxiliary consumables such as syringes, gloves, alcohol wipes, plasters, and pregnancy test strips. In Nigeria, women are typically required to take a pregnancy test before accessing most contraceptive methods (except condoms). Our field data suggested that the cost or inconvenience of pregnancy tests may present a barrier to access. During our second delivery in Katsina, we also piloted distributing only pregnancy tests in a third LGA to assess whether providing pregnancy tests alone can increase contraceptive uptake.

Investigating the Distribution of Contraceptives

An early analysis of historical data suggested that some regions would have to reallocate more than half of their contraceptives in order to match demand. This strongly suggested that improving the allocation of existing contraceptives was a necessary component of increasing contraceptive access. Our data shows that while the vast majority of facilities face significant stockouts, a small handful of larger facilities were frequently overstocked (though only relative to immediate consumption, and not in quantities large enough to risk substantial expiry or wastage).^[4]

However, the actual amount of contraceptives needed to satisfy demand seems to be fairly large, and the actual amount of contraceptives present in the system seems to be insufficient, with deliveries frequently being skipped because there are not enough contraceptives to send. While we expect that improving the allocation of commodities alone could unlock additional benefits, we expect that increasing the total supply will be significantly more impactful.^[5]

Together, these efforts have provided us with a rich and nuanced understanding of the contraceptive supply chain and a strong foundation to design interventions that are not only cost-effective, but also scalable and sustainable in local contexts. In Year 2, we’re building on this foundation to test our impact at scale and work toward embedding sustainable solutions into government systems.

We are deeply grateful to our exceptional local implementation partners, without whom none of this work would have been possible. Saida Mansur led the team at Sahara Women and Children Development Initiative, and Dr. Musa Abdullahi Sufi led the team at Sufi Innovation and Development Solutions.

Year 1 Spending

We received a generous unrestricted grant of $147,000 from the Charity Entrepreneurship Seed Funders Network and spent about $121,000 over our first 12 months. Our spending breakdown is as follows:

• $20,000 on supply chain and data visibility solutions, our local implementation partners, and 6 training days covering the 137 participating health facilities
• $12,000 on contraceptives for our supplemental deliveries
• $8,000 on Monitoring & Evaluations, including our local M&E staff and a part-time data operations specialist
• $15,000 on in-country travel and miscellaneous in-country purchases (e.g. a printer, training materials)
• $60,000 in co-founder salaries (2 FTE for 12 months)
• $6,000 on miscellaneous overhead including software, conferences participation, US incorporation fees, bank fees and fiscal sponsorship in our first 2 months

Updated Cost-Effectiveness Analysis at Scale

Based on our pilot results and updated long-term strategy, we have estimated the cost of additional procurement to meet demand in each state, as well as the expected increases in contraceptive consumption that our work is likely to generate.

Using method-specific efficacy rates, we model the number of additional Couple Years of Protection (CYPs, where one CYP means protecting one couple for one year) and the number of unintended pregnancies averted through increased availability of free commodities in the public health system. Preventing unintended pregnancies reduces maternal mortality and improves birth spacing, which significantly lowers under-five mortality.^[6] These health outcomes are the main drivers of our cost-effectiveness model.

We also model the morbidity burden of maternal conditions such as obstetric fistula, postpartum anaemia, and postpartum depression.

We have incorporated a number of significant discounts into our model, particularly in areas with greater uncertainty. For example, because our study was a pre-post study with control groups rather than a true RCT, we have applied a discount to account for other causes of consumption increases, as well as a discount accounting for the possibility that some of the increase in consumption was merely shifted from private market providers. We also apply discounts to account for generalising a limited study to a full year, as well as generalising across geographical areas. Even under these assumptions, our cost-effectiveness appears strong. You can explore our model in depth here, and a full walkthrough of our model is available here. 

We currently believe this model to be conservative. As an illustration, in our Year 2-specific calculations, we model the costs to distribute 125,000 CYPs, but we only model the benefits of 23,400 counterfactual additional CYPs. As we gather more evidence from scaling our programs to larger areas over longer periods of time and reduce our uncertainties, we may reduce some of our discounts and thus increase our projected cost-effectiveness.

Based on our current model at scale our estimates are as follows:

•  $7 per additional Couple Year of Protection
• $18 per unintended pregnancy averted

• $1300 per life saved, or $3100 only including maternal health benefits^[7] 

• $37 per DALY, or $82 only including maternal health benefits

While our charity is still in an early stage, we view this analysis as a promising sign for our future work. GiveWell’s current top recommendations range from $3500-$5500 per life saved, and they just published an article suggesting any program providing a Couple Year of Protection for less than $20 may be above their cost-effectiveness threshold. Our current model suggests that our program may be on track to become more cost-effective than GiveWell's threshold in our second year. We are encouraged by the potential of our approach and remain focused on monitoring and refining our program to ensure the greatest possible impact and cost-effectiveness.

Our Strategy for Year Two (And Beyond)

In Year 2, our work will focus on two main areas:

• Testing the impact of sustained increases in contraceptive availability across an entire state.
  We plan to evaluate whether a consistent increase in supply over a 12-month period leads to a lasting rise in contraceptive uptake. Specifically, we aim to understand whether the sharp increase observed during our pilot reflects a temporary surge in demand, or whether it can be sustained over time with continuous availability.
• Providing technical assistance to state governments to initiate their own contraceptive procurement.
  We will support key state governments in establishing the legislative foundation needed to supplement the limited supply they currently receive from the federal level. Building on this groundwork, we will then explore working to unlock and deploy domestic funding for procurement. This approach is designed to strengthen state-led systems and promote long-term sustainability.

Expanding Our Procurement of Contraceptives

We plan to study the impact of increased contraceptive stock at a large scale over a longer period of time. While all contraceptive methods are similarly easy to transport and store, as none of them require cold chains, there are significant differences in their cost-effectiveness. You can see a comparison of the cost-effectiveness of all methods (based on typical use and typical effectiveness) here.

Due to budget restrictions, during this study we will focus primarily on Implanon, a 3-year implant that offers 2.5 CYPs per dose with over 99% efficacy. At $0.65 per CYP, Implanon is the most cost-effective option of all methods that saw significant increases in consumption in our pilot.^[8] In addition to being more cost-effective, its long duration means Implanon is less sensitive to temporary stockouts. In contrast, short-acting methods such as condoms, pills, and injectables require frequent resupply, and even brief disruptions can lead to gaps in protection and increased risk of unintended pregnancy. We plan to continue to provide auxiliary consumables, such as surgical gloves, disinfectant, and pregnancy tests to ensure that all procedures inserting the commodities we donate are conducted safely.

Providing Technical Assistance for State-Funded Procurement of Contraceptives

In the current system, all contraceptives in the public system are procured at the Federal level, but this supply is insufficient and sometimes unreliable. A few states have set a precedent by passing legislation allowing them to start procuring contraceptives additional to the federal supply system. We believe that encouraging more states to adopt this change is very tractable, especially in the aftermath of the USAID cuts.

We believe there are two steps to this:

• Creating and adopting the legislative framework to procure State-Funded Family Planning Commodities
• Incentivising and assisting the creation and release of a budget line by the State Ministry of Health

Miri was involved in shaping this policy for a different Nigerian state back in 2023, and we are currently working with one state to help them adopt this legislation by the end of 2025. If you would like to discuss this work in more depth, please reach out to Miri.

Our technical assistance work will only promote specific methods over others to the extent that data suggests their relative demand, to ensure our work does not counterfactually reduce the availability of any method. Our current focus on Implanon in our own procurement does not change our long-term commitment to ensuring access to a full method mix that maximises women’s agency over their own bodies. Over the long term, our goal is not only to fill supply gaps ourselves, but to help strengthen the broader system to ensure long-term access to a full mix of contraceptive options. By working alongside government partners, we aim to make procurement more sustainable, responsive to demand, and well-funded at scale. This systems-level approach allows us to achieve a far greater impact than we could through direct delivery alone, driving lasting improvements across the supply chain.

Improving and Expanding our Monitoring & Evaluation

We aim to continue to refine our monitoring and evaluations system, improving the accuracy of our measurements and minimising costs as we scale. One key area will be ensuring we prevent the theft of commodities and identify if it does occur. We will continue and scale up our Year 1 “mystery clients” program, where we hire women from local communities to visit various facilities and ask for a family planning consultation. This helps us verify that clients are able to access the commodities available in the facility free of charge.

We are also trialing three ways to mark commodities we donate to reduce their resale value and help us identify if they appear on the black market. We are most excited to pilot the use of RFID labels, which will allow us to streamline inventory and track the flow of each individual item, identifying the exact source and time of any leakage. The cost per label is $0.03-$0.05, making them suitable even in our ultra low-budget context.

We are trialing a shift in our digital data collection strategy to include regular phone calls with facilities. While this approach has slightly higher monthly costs compared to mobile-based surveys, we believe it may save time for health workers, improve data validation, and ultimately prove more cost-effective in the long term.

As part of our commitment to measuring our impact, we will continue collecting comprehensive consumption data, including for commodities we did not supply. We aim to ensure we are driving a counterfactual increase in total contraceptive use, rather than merely subsidising consumption that would have occurred anyway.

Projected Cost-Effectiveness of Our Year 2 Work

We expect the direct impact of our implant procurement to more than offset our overhead and other projects (advocacy work, M&E refinement tests). Based on the same model we discussed in the Updated Cost-Effectiveness Analysis section, we calculated our expected cost-effectiveness of our Year 2 work alone:

• $12 per Couple Year of Protection
• $24 per unintended pregnancy averted
• $1,746 per life saved, or $4,174 only including maternal health benefits
• $35 per DALY, or $78 only including maternal health benefits

Budget and Funding Gap

We are eager to build on our successful pilot by expanding our work to entire states and helping shape state policy. We have received strong signals of interest from multiple government officials, but we are unable to begin our work until we have secured more funding.

We estimate our year two expenses at approximately $282,000, of which $30,000 has already been secured. We are currently fundraising to fill the remaining $252,000 funding gap.

With this funding, we will be able to:

• Provide 50,000 Implanon implants to public health facilities. Based on current models, we expect this to avert at least 12,000 unintended pregnancies and save approximately 160 lives.
• Achieve a policy change that enables at least one state to allocate part of its health budget toward the direct procurement of additional contraceptives, laying the groundwork for sustainable, state-led supply mechanisms.
• Expand and refine our monitoring and evaluation work to cover a broader geographic area, allowing us to test new approaches, increase our cost-effectiveness further, and better understand our impact at scale.

A detailed breakdown of our costs is covered in our budget.

Why Support Access to Medicines Initiative?

This organization was born out of a gap Family Empowerment Media identified in 2023, with stockouts of contraceptives being one of their main barriers to scale. The situation has only gotten worse since, especially due to the loss of USAID´s work on data, supply chains and the broader system infrastructure. By filling the most cost-effective gaps in the existing ecosystem we can enable millions to access contraceptives.

Our program does not contain any demand generation component, we focus solely on improving supply so our target population can actualise their preferences. We work to improve the existing system within Nigeria’s public sector to ensure free contraceptive access at scale, leveraging infrastructure and capacity created over the past few decades by donors and governments aiming to increase contraceptive prevalence. This focus on policy and system design helps us avoid wasteful duplication of resources, increase scale, and ultimately make our solutions sustainable long after our work winds down.

We have established strong partnerships both in the private sector and the government, and we have received strong early signs that this approach is promising. Several state governments have initiated contact and expressed interest in expanding our work.

Supply chains may not be particularly exciting, but they are foundational to every aspect of modern life. We leverage the innovations and technical solutions used by corporations in high-income countries and adapt them to serve some of the world’s most marginalised communities.

Alongside running this intervention, Miri completed MIT´s Supply Chain Management Micromasters and is applying these insights to our technical assistance work in Nigeria. Evan graduated summa cum laude with a degree in Mathematics and Physics from the University of Arizona and is using their technical expertise to ensure the most rigorous, data-driven interventions possible.

As an early-stage organization, our work carries significantly more uncertainty than more established programs, but we believe that our expected impact is large enough to warrant the risk. Our cost-effectiveness modeling suggests that this intervention may be competitive with some of the best opportunities available in global health and development today.

We recognise that different worldviews evaluate the impact of family planning through different moral frameworks, and some may see our work as net negative. While we respectfully acknowledge these perspectives, we do not personally find them persuasive.

We believe that access to contraception is essential for promoting health and well-being, as well as for advancing autonomy and gender equality. For those who share this view, we see our work as a highly leveraged opportunity to expand access in a way that is both cost-effective and scalable.

How You Can Help

Advise: We are eager to connect with academics and other experts who can help us ensure the highest standards possible in our study design, implementation, and impact analysis.

Donate: If you would like to support us, please consider donating by clicking the button below. All donations are tax-deductible in the United States. If you are considering a larger contribution, we encourage you to get in touch by emailing us. If you require your donation to be tax deductible in a country outside of the United States, please let us know and we might be able to arrange it.

Tell a Friend: Know someone who might be interested in our work? Please feel free to share this post, or send a link to our website (https://www.accessmedicines.org).

Stay up to date: Want to hear more about our work? You can browse our past newsletters here, and you can subscribe to our newsletter here.

Thank you so much for your support. If you have any questions, please drop a comment below or contact us here.

Acknowledgments

This charity would not exist without the immense support of Joey Savoie, Anna-Christina Thorsheim, and Steve Thompson. We are also deeply grateful to our incredible advisors, including Patrick Stadler, Brechtje van den Bosch, Curt Bowen, Devon Fritz, Keyur Doolabh, and many others who have generously shared their time and expertise.

We are especially thankful to our board members Tony Senanayake, Supriya Bansal, and Rowan Lund, as well as to the Ambitious Impact Seed Funder network and the broader Ambitious Impact community for their ongoing support.

We are grateful to Naomi Panovka for her valuable help in editing this post. All omissions and mistakes in this post are entirely our own.

1. ^{^}

    While we look forward to engaging deeply with GiveWell’s recently published analysis on the value of contraception, it was released after we had completed the drafting of this forum post. As such, we have not yet incorporated their estimates into our cost-effectiveness models or benefit calculations, but we plan to do so and publish an updated analysis in the coming months.

   Previously, we referenced an alternative model of economic benefits that diverges significantly from GiveWell’s assumptions. Although this was never a central part of our analysis, we have removed it for now and will revisit it once we’ve had time to investigate the differences more thoroughly.

   Edit: We have now pulished an update that incorporates GiveWell's model into our work.

2. ^{^}

    We will consider expanding to other essential medicines once our contraceptives intervention is stable.

3. ^{^}

   The numbers reported here are no longer up to date. We have finished collecting our pilot data, refined our methodology, and aligned our CEA with GiveWell’s new report on contraception. Please check our recent post for updated results.

^{^}

 Female condoms seem to be the exception here - we have encountered several facilities with expired female condoms due to very low demand.

^{^}

 It should be noted that if additional procurement is not informed by consumption trends, it is unlikely to be as impactful as it could be. We will seek to expand our monitoring and evaluations and improve data collection within the supply chain to ensure that procurement is data-driven to match demand.

^{^}

 Allowing women to delay their next pregnancy increases the spacing between births, allowing their body to recover and be better prepared for the next pregnancy they do have. This is what lowers under-five mortality - we do not count impacts on births that do not happen.

^{^}

 We separate maternal benefits from child benefits because while there is strong evidence that family planning improves neonatal outcomes, the magnitude of this effect has more uncertainty than that of averting maternal mortality. We believe that the case for our intervention is strong even excluding this effect.

^{^}

 While IUDs are more cost-effective in theory, we saw no significant change in consumption in our pilot. We believe this is because IUDs are stocked out much less than other commodities. Because they are so cheap, we may provide some IUDs to facilities that are stocked out in year two to try and measure any potential increase, but this is less of a priority relative to our other work.

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